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· What types of potentially fraudulent or abusive behaviors can occur within hospitals? 

· Include an example from a publication or article posted within the last five years.

According to McMacken, 2021 "Fraud is the intentional deception to secure unfair or unlawful gain, or to deprive a victim of a legal right." while "Abuse is defined as practices that are inconsistent with accepted sound fiscal, business, or medical practices, and result in an unnecessary cost or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for health care." According to Rudman et al., 2009 Healthcare Fraud and abuse accounts for about 3 to 15 percent of annual expenditures in the United States which amounts to about $100 - 170 billion annually. Some examples of healthcare fraud and abuse include misrepresentation of the type or level of service provided, misrepresentation of the individual offering the service, misusing codes on a claim, or billing for services that were not medically necessary. "Raritan Bay Medical Center agreed to pay the government $7.5 million to settle allegations that it defrauded the Medicare program, purposely inflating charges for inpatient and outpatient care, artificially obtaining outlier payments from Medicare." (Rudman et al., 2009)

· Describe how accreditation helps improve the quality of care delivery process.

· Provide an example for a hospital or hospital system. 

Accreditation is the process in which healthcare organizations are evaluated by an independent organization to demonstrate their ability to meet predetermined criteria and standards. The AAAHC, The Joint Commission, and the National Committee for Quality Assurance are examples of Healthcare accreditation organizations that create a set of standards with the help of industry experts. These are the standards that healthcare organizations need to comply with to maintain accreditation status. According to the CDC, Healthcare accreditation is important for several reasons including: 

"

· Stimulate quality improvement (95%)

· Improve accountability and transparency (89%)

· Improve the capacity of the department to provide high-quality programs and services (85%)

· Strengthen the health department’s relationship with key partners in other sectors (e.g., healthcare, social services, education) (78%)

· Help the health department use health equity as a lens for identifying and addressing health priorities (73%)

· Increase the extent to which the health department uses evidence-based practices (68%)

· Strengthen the utilization of resources (68%)" (CDC, 2022) 

An example of a hospital accreditation is The Joint Commission's Gold Seal of Approval. According to The Joint Commission receiving a Gold Seal of Approval means that the facility meets The Joint Commission’s rigorous performance standards in delivering quality, safe care. "St. Luke's has earned The Joint Commission's Gold Seal of Approval® for accreditation by demonstrating compliance with The Joint Commission's national standards for healthcare quality and safety in hospitals. The accreditation award recognizes St. Luke's dedication to continuous compliance with The Joint Commission's state-of-the-art standards." (St. Luke's Hospital, 2014)

References

CDC. (2022, July 20). CDC - Benefits and impacts of accreditation - Health department accreditation - STLT gateway. Centers for Disease Control and Prevention.  https://www.cdc.gov/publichealthgateway/accreditation/benefits.html

The Joint Commission. (n.d.). We received the Gold Seal of Approval® from The Joint Commission What does this mean? A Trusted Partner in Patient Care | The Joint Commission.  https://www.jointcommission.org/-/media/documents/the-joint-commission/tjc_goldseal_brochurepdf.pdf?db=web&hash=3667456A9805A95D8EE1EFD403D29554&hash=3667456A9805A95D8EE1EFD403D29554

McMacken, M. (2021, November 19). Health care fraud and abuse. Johns Hopkins Medicine, based in Baltimore, Maryland.  https://www.hopkinsmedicine.org/johns_hopkins_healthcare/providers_physicians/health_care_fraud_and_abuse/

Rudman, W. J., Eberhardt, J. S., Pierce, W., & Hart-Hester, H. (2009, September 16). Healthcare fraud and abuse. PubMed Central (PMC).  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2804462/

St. Luke's Hospital. (2014, June 19). St. Luke's awarded re-accreditation from the Joint Commission. St. Luke's.  https://www.slhduluth.com/news/2014/june/st-lukes-awarded-re-accreditation-from-the-joint/

(American Psychological Assoc.) Paveljit Bindra. (2018). The Core Elements of Value in Healthcare. Health Administration Press.

Olivia

Below is my response to our week five discussion questions and additional article reviews on the subject matter of fraud and accreditation in healthcare systems. Looking forward to your response.

What types of potentially fraudulent or abusive behaviors can occur within hospitals?

*Include an example from a publication or article posted within the last five years.

The potential scenarios of defrauding healthcare facilities and hospitals can manifest in a combination of approached methods of misconduct, alterations, and neglect. Examples can be displayed through physicians alongside the extended organization services, as well as healthcare members' involvement. Additionally, any third-party modifications made in conjunction with provider kickbacks and unwarranted patient services can justify deception (Paramount, 2022). 

One such example accounts for a claim and consequential one billion dollars monetary action of fraudulent telemedicine-based specialty healthcare. The accounted defrauding incorporated self-suiting cardiac referrals, bribed treatment evaluations, and unnecessarily authorized requests for cardiac-related medical equipment resulting in an accumulation of nationwide healthcare systems charged with fraud (U.S. Department of Justice, 2022).

Describe how accreditation helps improve the quality of the care delivery process.

*Provide an example of a hospital or hospital system.

The use of implementing a trustworthy appraisal process and subsequent healthcare industry accreditation enables these wellness facilities and health systems to evaluate determined audits, expected defaults, and required quality improvements (Bindra, 2018). This marketing-based format of approved and trustworthy rating creates a successful organization profit, ongoing exemplary delivery compared to its competitors, plus sustainability of its services (Bindra, 2018). 

This unique form of review from an outside participating assessment facilitator creates an unbiased and strict review for improvement purposes. These organizations consist of the Joint Commission, National Committee for Quality assurance, and Accreditation Association for Ambulatory Health Care (AAAHC) as professional verification services (Power DMS, 2020).

Recently a prominent hospital in Washington state lost its accreditation after a professional attendant at St. Michael Medical Center called for supplementary aid through the use of 911 and extended fire department services within its emergency department (Toay, 2022). The nurse in question felt pressure amidst a staffing shortage and leadership difficulties. Additionally, before this incident the medical center in Silverdale, Washington was also flagged for having failed facility and service standards a few months prior relating to structural safety guidelines, accurate pharmaceutical procedures, and not sustaining proactive inspections of medical equipment (Toay, 2022). The hospital, however, does have the opportunity to request an appeal and, as assured by the president of St Michaels, that "the hospital takes findings for improvement seriously." (Toay, 2022).

Thank you for engaging this week, and I hope everyone continues to have a great weekend.

Silvia Brestak

References:

Bindra, P. (2018). Chapter 10: Accreditation and High Reliability. In The core elements of value in healthcare. Health Administration Press.  https://eds-p-ebscohost-com.ezproxy.umgc.edu/eds/ebookviewer/ebook/bmxlYmtfXzE4Mzg5OTNfX0FO0?sid=4952bb1b-3b1a-4794-9354-545510d6b298@redis&vid=0&format=EB&rid=1

Paramount. (2022). Examples of fraud, waste and abuse, paramount health care. Paramount Health Care.  https://www.paramounthealthcare.com/fraud-waste-and-abuse/examples-of-fraud-waste-and-abuse

Power DMS. (2020, December 22). Impact of accreditation on quality in healthcare. powerdms.com.  https://www.powerdms.com/policy-learning-center/impact-of-accreditation-on-quality-in-healthcare#:~:text=Simply%20put%2C%20accreditation%20in%20healthcare,prove%20compliance%20with%20the%20standards

Toay, A. (2022, November 9). Silverdale hospital where nurse called 911 for help amid staffing issues could be denied accreditation. king5.com.  https://www.king5.com/article/news/health/st-michael-medical-center-accreditation-staffing-resignations/281-d664276b-85f1-472d-bd3e-04ea8716a85d

U.S. Department of Justice. (2022, July 20). Justice Department charges dozens for $1.2 billion in health care fraud. justice.gov.  https://www.justice.gov/opa/pr/justice-department-charges-dozens-12-billion-health-care-fraud

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